GW1--04784_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
I.Well Contractor Information: I
Taylor Ray Boger :14.WATER ZONES
FROM 'It) DESCRIPTION
Well Contractor Name ft. ft.
4614-A ft• ft.
NC Well Contractor Certification Number 15.OUTER LASING(for multi-case :wels)OR LLNER(if applicable) •
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft• 63 ft• 6.25 in. #21 PVC
Company Name iER CASING OR TUBING(geothermal closed-loop) ` -
409156-2 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Suite.Variance,injection,etc.) ft• p, in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIA MIA ER SLOT SIZE: THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geotheral(Heating/Cooling Supply) EIResidential Water Supply(single) f(' ft- m.
m
❑industrialiC'ommercial ❑Residential Water Supply(shared) 18 GROUT
FKUM "f0 MAT ERLAI. FAIPL ACE MF.NT METHOD&AMOUNT
['Irrigation 0 ft• 20 ft• Bentonite Pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft. Cap Top with Bentonite Chip;
Injection Well: — It. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
-FROM TO \1AT Fltt V. FAI PI At TM ENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft it
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control L
20.DRILLING LOG(attach additieupl sheets if oecessary)
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardaess,soil/mck type.grain sire.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 63 2 OVER BURDEN
7-23-2024 63 ft• 385 ft• GRANITE
4.Date Well(s)Completed: --Well iD# ft. `kit-It. .v•"�v S y
5a.Well Location: rt. e. L.
SJS MADISON INVESTMENTS LLC ft. ft. AUG 1 4 2024
R.
Facility/Owner Name Facility MN(if applicable) ft, ft.
456 WINDSWEPT RIDGE ROAD MARSHALL, NC Ir:& 9•.t,.'. I•.-r.•y4st4 u
Physical Address,City.and Lip .::21.REMARKS`
MADISON 9726-44-3485 THIS WELL WAS SELF-CERTIFIED
County Parcel Identification No.(PIN) 1
Ste.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iatllong is sufficient)
N W 7-25-2024
Sig of led ell ntractor Date
6.Is(are)the well(s): fr7Permanent or ❑Temporary By signing this form,1 hereby certify that the swills)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or EtNo copy of this record has been provided to the well owner.
t/this is a repair,fill out knolls'well construction information and explain the nature of the
repair under Ii?I remarks section or on the back of this Jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if.different(example-3(ii 200'and 2(q:100') construction to the following:
10.Static water level below top of casing 80 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: RIG 24c.For Water Supply&Injection Wells:
PILLS Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 35 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013